Transcript Emotional issues in cancer - psychiatry

PSYCHOLOGY OF PAIN
Definition: International Association for the
Study of Pain:
• Sensory and emotional negative experience
- induced by or related with real or imagined tissue
lesions, or
- described in terms that refer to such lesions.
Components:
• Physiological: receptors, pathways, biochemical
processes in the tissues and cells, etc
• Behavioral: mimics, gestures, etc that accompany the pain
• Subjective: thoughts, feelings, representations connected
with pain
Classification:
1. Acute pain:
- between 6 weeks and 6 months
- associated with anxiety (it may signal life threat)
•
Superficial:
- located in derma, mucosae; sharp, delineated
•
Profound:
- muscles, membranes, internal organs
- imprecisely delimited, less intense
- more persistent (in time) than the superficial one
- described by the patient as burning sensation, pressure,
pulling, tearing etc
2. Chronic pain:
-
lasts more than 6 months; located mostly in internal organs
associated with sensations of compression
distress for the patient and family
•
-
benign, recurrent:
Highly intense
recurring episodes, separated by pain-free intervals – for
example migraine
•
persistent: variations in levels of intensity, ex back pain
•
-
Progredient:
In rheumatoid arthritis, cancer, etc
intensity – increasing constantly
Theories of pain:
• Nonspecific model (Weddel, 1962):
there are no specific pathways of perception for pain;
pain occurs through intense stimulation of nonspecific
receptors
• Specificity (von Trey, 1985):
there are specific stimuli for specific receptors and
specific pathways of transmission
Theories of pain:
• Gate control (Melzack & Wall, 1965)
a neural mechanism located in the gelatinous substance
of the medulla spinalis – stimuli are either transmitted,
or blocked
The gate closes (pain is not transmitted) when fibers A
beta (non-related with pain) are stimulated (these
stimuli have priority)
The gate is opened by
 Activity of fine fibers A delta and C (these fibers are
the specific pathway for pain stimuli)
 Very intense stimuli
 Information interpreted as painful
 Feelings of anxiety, sadness, depression associated
with stimuli
Psychosocial factors related to perception of
pain:
• Sex:
differences related to sexual hormones
higher frequency of non-pathological pain in women (ex
childbirth)
genetic differences between sexes
• Age:
differences in perception and control mechanisms of the
pain
ethnic differences in the behavioral and social
expression of pain
Psychosocial factors related to perception of
pain:
• Differences in personality traits:
introverted persons are more reactive to pain and have a
lower pain threshold
subjects with negative beliefs linked with potentially
painful events tend to over-represent the pain
subjects with a history of abuse in childhood develop
 pain-prone personalities
 an inability to verbally express negative feelings
 the need to be punished when feeling guilty
 higher pain threshold
Acute pain is influenced by:
• Past experience of pain
its meaning as alarm signal for the person
subject’s expectations (I should have a certain level of
coping abilities for pain)
• Sources of information
Family, peers, medical team
When the patient is informed about purpose, duration
and methods of a medical intervention before that
intervention, the negative impact associated with the
perception of pain (awareness about pain)
decreases
Acute pain is influenced by:
• Coping style of the subject
 emotion-centered: distracting attention from pain
works better
 problem- centered: information gathering works
better
• The therapist
 empathy, relational abilities
 knowledge, expertise, experience
 trust in the prescription
 prestige, authority
Chronic pain is influenced by:
• The significance
 the meaning of chronic pain is different from acute
pain
 nevertheless, the individual feels (senses) acute and
chronic pain in the same way
• Individual’s affective states:
 anxiety, depression, hostility, etc enhance pain
perception
 negative affect influences information processing
 negative affect focuses the person on the painful
perception
Chronic pain is influenced by:
•
•
•
•
•
Cognitive style:
catastrophic thinking (“this means I will die”)
overrepresentation of pain (“this means that I have a
serious illness”)
negative expectations concerning consequences of
pain (“this means I will lose this leg”)
altered primary and secondary evaluations of pain
stimuli
PSYCHOLOGY OF CANCER
• Cancer – regarded as the prototype of human
suffering
• Specific surgical interventions for different
cancer types – since 1900
• Radiation therapy in cancer – since 1915
• Chemotherapy in cancer – developed since
1960
• Immunotherapy in cancer – has developed
since 1970
• Clinical trials, new drugs discovered every
day – last 2 decades
The field of psychooncology was founded in 1970
by Holland (oncologist), with 6 main branches:
1. The role of psychologic, social and behavioral factors
involved in mortality and morbidity in cancer
2. Emotional issues in patient and family dealing with the
diagnosis of cancer and treatment
3. Quality of life in cancer patients
4. Bioethics in oncology (communication of diagnosis
and prognosis, euthanasia etc)
5. Alternative therapies in oncology
6. Stress and burnout syndrome in medical staff involved
in treatment of cancer
Psychological, social and behavioral
issues in cancer
Studies since the 1950’s have concluded:
•
•
Depression is a major risk factor in
development of cancer
Subjects which developed cancer had some
common features, such as:
- the overwhelming need to live in harmony
and to be accepted by others
- repressed anger, aggresivity, irritability
- apparently well-adjusted socially
- repressed positive emotions
• Specific to subjects with cancer
Repressed emotions and overrepresented
rationalization (concrete thinking, lack of
imagination)
Learned helplessness, depression, despair,
leading to: decreased motivation and activity
and negative affect
Coping style: perfectionism, rigidity, selfcontrol, adherence to conventions, stoicism
Behavioral and social factors
involved in cancer
• Lifestyle:
Extended, unprotected exposure to sunlight
Sleep deprivation, lack of exercise
Unbalanced diet
Smoking, alcohol etc
• Social factors – certain differences between
social classes (concerning access to healthcare
services, social services, to other facilities etc)
Emotional issues in cancer –
Elizabeth Kubler-Ross
•
The book On death and dying – she describes
6 emotional stages in the process of dealing
with cancer:
1. Hope / anxiety:




Symptoms
The diagnosis has not been set yet
The subject feels that something is not right
He considers cancer as a possible diagnosis
Emotional issues in cancer –
Elizabeth Kubler-Ross
2. Denial (no, not me!):
 When the diagnosis is ascertained
 Increased risk of suicide.
 Denial may be an efficient defense mechanism
(protecting the subject from the emotional impact of
information)
 It may generate decreased compliance, if extended
3. Anger (Why me?)
 The patient seeks causes, explanations
 Cancer is interpreted as: well-deserved/ undeserved
punishment
 The interpretation may increase anger and interfere
with compliance
Emotional issues in cancer –
Elizabeth Kubler-Ross
4. Negotiation (please, not me!):
 Bargaining with the Divinity
 The subject is willing to compromise, to fight
for his health
 The most effective stage for interventions
5. Depression (Yes, it’s me...)
 The signs and symptoms cannot be denied
 The cancer may progress
 Therapy may prove ineffective
Emotional issues in cancer –
Elizabeth Kubler-Ross
6. Acceptance:
 Final stages – death is seen as a release
 It does not occur in all cancer patients
 Highly unstable subjects, who have to deal
with more than one crisis situations, do not
reach this stage
Emotional issues in cancer –
Elizabeth Kubler-Ross
•
Actually, we can find in any stage a mixture of
 hope (for a miracle) and anxiety (permanent)
 guilt (‘I have cancer, I am a burden for the others’)
 shame, fear of death and unknown
•
•
Cancer (diagnosis, assessments, treatment)
entails an existential crisis
The subject’s adjustment to crisis depends on
 previous experiences
 perceived future threats
 available resources: biological, psychological,
psychosocial support
Early stage of cancer
• The early symptoms and signs – it does not coincide
with the decision to see a physician
• Denial leads to delayed medical assessment, which
increases severity of symptoms
 In breast cancer – a delay of 3 months, in rectal cancer – 7-10 months
• Causes of delay in requesting medical care:
 Psychosocial factors (low level of health education in some
social layers, old age) may be linked to:
-
failure to recognize cancer
failure to understand the importance of regular check-up and early treatment
 Psychological: avoidance as defense mechanism: fear of
- clinical assessment, suffering
- bad news
- mutilation
 Poor therapeutic relationship of patient with physicians –
based on previous unpleasant experiences
Early stage of cancer
• Factors involved in seeking early medical care:
Symptoms:
- Complex, obvious symptoms
- Physical pain
A certain level of medical information and
education
Good therapeutic relationship
Emotional issues
- Impulsiveness
- High levels of anxiety
The stage of diagnosis
• Situational crisis, shock – cancer is represented
as death sentence – approx. 3 months
 Anxiety
 Pessimism, despair
 Vulnerability
 The essence of the individual’s existence, the
relationships with the world are being questioned
• After 3 months: the patient worries less about
the illness, reaches acceptance of
 Cancer
 Necessity of treatment
The stage of diagnosis - family
• Family members experience negative feelings
elicited by the diagnosis of cancer
Anger, despair
Fear of death and dying
• Negative emotions may lead to impaired
communication between patient and family
Lack of communication
Distorted communication (listening and
understanding are overlooked)
The stage of treatment
• It requires adjustment: the patient
 Is full of hope
 Experiences side effects of therapy – financial,
psychological, physical
• A treatment has the highest chance to be
accepted if suggested at the end of the
diagnosis stage
• Radiation therapy – 2-6 weeks – side effects:
 Fatigue, hair loss, skin lesions
 Digestive disorders, loss of appetite
 Social impact
 Affected self-image
 The patient fears that it will be ineffective
The stage of treatment
• Alternative therapies (in the search for a miracle
cure for cancer) – instead of/ associated with
classical therapies
Metabolic, nutritional
Imunological
Psychological, spiritual healing
• Risk of alternative therapies:
Side effects, infections, weight loss
Financial burden, wasted time (when
classical therapies are discarded)
The stage of remission
• Although desired and expected for, it is also a
stage of crisis
• The evolution from the sick role towards the
survivor role
• Remission does not always means healing
• Emotional distress
 The patients feel abandoned, demoralized
 The patients feel disoriented, experience loss of control
 Constant anxiety, increased by any new symptom
• The patient is focused on physical experiences:
 Seeking any possible new symptom or sign of disorder
 Fatigue
 Digestive disorders
The stage of remission
• Readjustment to professional requirements
• Relationships with colleagues may prove
difficult
The subject is sensitive to the issue of
cancer
Colleagues
- Mixed feelings, aggressivity
- Overprotection, admiration
The stage of relapse
• Sometimes – many months, fluctuations in
patient’s status
• Anxiety, depression
• Hope in efficient therapies disappears
• The end of a long period of painful uncertainty
• Some patients try alternative experiential
therapies, as a way of reclaiming control over
the illness
• Others refuse any other new therapies
The terminal stage
• Death, dying, bereavment issues
Gradual severing of emotional ties with the
peers, family
Gradual severing of emotional and rational
ties with reality
The patient is allowed by loved ones to pass
on (dying with dignity)